Thank you for your support of WiHPCA! Please complete the agency membership application thoroughly. A benefit to the agency membership is you may include an unlimited number of employees and/or staff. These individuals will have access to all of WiHPCA's benefits when they are included with the agency. WiHPCA annual dues are calculated at $0.12/patient hospice day with a minimum of $500 and maximum of $8000. To accurately invoice your agency, please submit the number of agency hospice days from Sept 2024 - Aug 2025. Once we receive your application, you will receive an annual dues invoice based on the number of patient hospice days submitted.
Name
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First
Last
Credentials
Title/Position
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Organization:
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Email:
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Work Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Total number of patient hospice days from Oct 2023 - Sept 2024:
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Employees you would like added to your WiHPCA agency membership. Please include full name, credentials, position and email address.
Submit
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